Service Definition

Psychosocial Rehabilitation is a program of two or more consecutive hours per day
provided to groups of adults in a nonresidential setting. Individuals must demonstrate a
clinical need for the service arising from a condition due to mental, behavioral, or
emotional illness that results in significant functional impairments in major life activities.

This service provides education to teach the individual about mental illness, substance
abuse, and appropriate medication to avoid complication and relapse and opportunities to
learn and use independent skills and to enhance social and interpersonal skills within a
consistent program structure and environment.

Medical Necessity Criteria

The service-specific provider intake, as defined at 12VAC30-50-130, shall document the
individual's behavior and describe how the individual meets criteria for this service.
Individuals qualifying for this service must demonstrate a clinical necessity for the service
arising from a mental, behavioral, or emotional illness that results in significant functional impairments in major life activities.

Individuals must meet both Criteria A and B to qualify for reimbursement.

Criteria A

Individuals must meet two of the following criteria on a continuing or intermittent basis:

Experience difficulty in establishing or maintaining normal interpersonal
relationships to such a degree that they are at risk of psychiatric hospitalization,
homelessness, or isolation from social supports;

Experience difficulty in activities of daily living, such as maintaining personal
hygiene, preparing food and maintaining adequate nutrition, or managing
finances to such a degree that health or safety is jeopardized;

Exhibit such inappropriate behavior that repeated interventions documented by the mental health, social services, or judicial
system are or have been necessary; or

Exhibit difficulty in cognitive ability such that they are unable to recognize
personal danger or significantly inappropriate social behavior. Cognitive
here is referring to the individual’s ability to process information, problemsolve
and consider alternatives, it does not refer to an individual with an
intellectual or other developmental disability.

Criteria B

Individuals must meet one of the following criteria:

Have experienced long-term or repeated psychiatric hospitalizations; or

Experience difficulty in activities of daily living and interpersonal skills; or

Have a limited or non-existent support system; or

Be unable to function in the community without intensive intervention; or